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Micro Suction Ear Wax Removal Consent Form

To safely remove any wax or foreign bodies present within the ear canal, it is important that the clinician is made fully aware of anything which may have a bearing on the procedure. Please answer the following questions regarding your hearing health by ticking and completing the relevant boxes:

Do you suffer from any condition that causes balance problems or vertigo attacks? *

Yes
No

If you begin to feel even the the slightest bit dizzy or faint during the procedure it is important that you let the clinician know at the very first sign.

Have you had any fluid discharge from your ear/s within the last 30 days? *

Yes
No

Have you suffered any pain in your ears within the last 30 days? *

Yes
No

Pain Level

Slight
Significant
Excrutiating

Are you aware of, or suspect you may have a perforated ear drum? *

Yes
No

Which ear?

Left
Right
Both

Have you tried to remove the wax yourself other than using ear drops? *

Yes
No

Have you had any surgical operations on your ears, nose or throat? *

Yes
No

Which one?

Left ear
Right ear
Nose
Throat

How long ago?

(Years, months)

Are you currently under an ENT Consultant or receiving any treatment regarding your ears? *

Yes
No

Treatment Details

Are you using any antiplatelet or anticoagulant blood thinners? *

Yes
No

(E.g. Warfarin)

Blood Thinner Details

Do you have persistent tinnitus (usually a ringing or buzzing noise in the head or ears)? *

Yes
No

Which ear/s?

Left
Right

Have you had wax removed from your ears previously? *

Yes - micro suction
Yes - other
No

Are you aware of any reason as to why you should not proceed with micro suction? *

Yes
No

Please discuss this with your clinician before signing this form.

Patient Name: *

Last Name *

Phone Number *

Patient signature: *

(or signature of a parent if under 16, guardian or attorney if appropriate)

Does the signature above belong to the patient?

Yes
No

Signee Name

Reason for signee not being the patient

Date of signature: *

This form is completed to the best of my knowledge.

Consent Terms *

I have read and understood the terms of service and am willing to be bound by them.